164R Focused Disease Management through CPRS: Diabetes

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164R Focused Disease Management through CPRS
Diabetes Hyperlipidemia

• Rachel Chandra, PharmD
• Clinical Pharmacy Specialist
• Brian V. Burke, MD, FACP
• Chief, Metabolism Diabetes
• Dayton VAMC

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• Please write questions on a 3 X 5 card
• Give to assistants in the room
• Questions will be answered at the end of the
  presentation

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Objectives

• Describe the available tools to efficiently enter
  orders
• Identify electronic tools available in CPRS to
  aid in the management of patients with chronic
  diseases
• Evaluate local menus and orders for efficiency

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Hyperlipidemia Background

• Lipid performance measures not at goal
• High statin dollars
• VISN, National LDL goals consistently NOT met

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Analysis of report

• 4,000 patients not at LDL goal
• 550 patients within 6 of LDL goal
• Formulary vs. Non-Formulary (NF)
• ? on a NF agent
• 42 on a NF agent not at goal
• Just in time for conversions lovastatin,
  ezetimibe/simvastatin atorvastatin

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What should we do with this information?

• We can ignore this information
• Demonstrate an attempt to do something
• Provider problem not pharmacy
• Inform the providers and do nothing more
• Develop a hospital based strategic plan between
  medicine pharmacy in efforts to obtain LDL
  goals

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Historical Challenges
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Historical Positives
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Current Hyperlipidemia Challenges

• Inadequate staff
• Overworked staff
• NF approvals inconsistent
• Increasing patient load
• Decreasing provider availability
• Diverse treatment groups
• Lipid Clinic - Not a new phenomenon
• ?? FTE for clinic
• What should we do now?

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Patient Mapping
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Hospital Based Treatment Pathways
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Objectives for Lipid Template

• Decrease CV risk
• Obtain VISN National goals
• Distribute workload - Not a provider problem
• Simple process
• Flexibility in time

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Lipid Template Options

• Notes
• New notes
• Hyperlipidemia (HLP) assessment
• HLP assessment telephone
• Lipid medications

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Lipid Template for Pharmacists Nurses
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Click here
Paste here
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• Assessment template
• Provider Medication template

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Provider Lipid Pharmacy Medications

• Patients currently on a statin
• Statin naive

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Patients currently on a statin

• Maximum tolerated dose of formulary statin
• Patient developed an ADR to formulary statin
• Additional LDL reduction needed

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Patients currently on a statin

• Maximum tolerated dose of formulary statin
• Patient developed an ADR to formulary statin
• Additional LDL reduction needed

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Patients currently on a statin

• Maximum tolerated dose of formulary statin
• Patient developed an ADR to formulary statin
• Additional LDL reduction needed

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Lipid Pharmacy Medications

• Patients currently on a statin
• Statin naive

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Click here
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Paste here
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Upon Completion of template

• Click finish
• Labs are ordered
• Medications are ordered
• Nutrition consult are ordered
• One signature

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List of Websites

• https//vhav10share.v10.med.va.gov/sites/Dayton/CP
  RS/CPRS20V2620Demos/Calculators/LDL_REDUX_CALCii
  .mht
• http//hp2010.nhlbihin.net/atpiii/calculator.asp?u
  sertypeprof

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Inpatient Hyperglycemia and Chronic Disease
Management

• What is the connection?
• Why bother?
• How does the DAVA protocol work?
• Who makes it work?
• Where s the interface with CPRS?
• When will he stop using these pronouns?

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Inpatient Hyperglycemia and Chronic Disease
Management

• What is the connection?
• Diabetes Chronic Disease
• Over 50 of costs are Inpatient related ADA, 2008
• Decreased LOS Multiple
• 467 return on investment Newton,2006
• Missed opportunity cost Diabetic Patients
• 30-50 risk of re-hospitalization in next12
  months
• Poor Control Average A1c 9 Umpierrez
• Behavior Change and Stress

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Inpatient Hyperglycemia and Chronic Disease
Management

• Why Bother?
• EBM and Expert Opinion
• ADA Inpatient Guidelines
• ACE/ADA Consensus Statement on Inpatient Diabetes
  and Glycemic Control
• Joint Commission
• Order sets may decrease insulin errors Magee,
  2007
• Independent marker of in-hospital mortality
  Umpierrez, 2002
• Patient satisfaction? Opinion, 2008

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Inpatient Hyperglycemia and Chronic Disease
Management

• How does the DAVA SC protocol work?
• Basal Insulin Glargine
• Bolus Correction Insulin Aspart
• IV insulin Regular
• Discharge insulin (s) based upon Inpatient Doses

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Inpatient Hyperglycemia and Chronic Disease
Management

• How does the DAVA SC protocol work?
• Nurse Managed Championed
• Resident Initiated Titrated
• Patient Health Education Collaboration
• Inpatient Diabetes Consult Service Back-up
• Laboratory Data Analysis
• Nutrition Sponsored
• Administration/CEB/Pharmacy endorsed

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Inpatient Hyperglycemia and Chronic Disease
Management

• How does the DAVA SC protocol work?
• CPRS Protocol
• Dose calculation/guide
• CPRS Hypoglycemic Protocol
• CPRS Discharge Guide

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Inpatient Hyperglycemia and Chronic Disease
Management

• How does the DAVA SC protocol work?
• Bedside Glucometers
• Uploaded multiple times/ day (CPRS)
• House officer titrated per protocol (CPRS)
• FSBG, Insulin and Meals
• Nursing protocol (unit)
• Hypoglycemia
• Nursing protocol (CPRS)

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Inpatient Hyperglycemia and Chronic Disease
Management

• Summary
• Dayton VA CPRS inpatient insulin protocols
• improve the utilization and efficiency of complex
  medical management
• reduce errors
• reduces LOS in diabetic patients
• acts as a conduit for outpatient chronic disease
  management

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Presentation Summary

• Chronic Illness
• Creates additional demands
• Multi-disciplinary, -tasking,- faceted
• Complexity becomes routine
• CPRS
• Assimilates critical data
• Facilitates reaction better care

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Contact Information

• rachel.chandra_at_va.gov
• brian.burke_at_va.gov
• mary.gochenour_at_va.gov